NEUROLOGY SAMPLE HISTORY OF PRESENT ILLNESS This 51-year-old whi e !e"ale #a ie$ was ad"i ed i$ he hos#i al !

ro" he e"er%e$&y roo" 'e&a(se o! "ar)ed wea)$ess* res#ira ory dis&o"!or wi h shor $ess o! 'rea h a$d &hes &o$%es io$+ She also had sl(rred s#ee&h a$d she was &o$!(sed a$d disorie$ ed o$ ad"issio$ o he e"er%e$&y roo"+ The #a ie$ was &o"#lai$i$% he $i%h 'e!ore ad"issio$ o! &hes #ai$s radia i$% o her 'a&)+ She he$ de,elo#ed de,elo#ed "ar)ed wea)$ess a$d res#ira ory dis ress+ She 'e&a"e hy#o-e"i& a$d i$ he e"er%e$&y roo"* she was !o($d a$e"i& a$d she was ad"i ed !ro" he e"er%e$&y roo"+ The #a ie$ was ad"i ed !or #ossi'le #$e("o$ia* a$e"ia* a$d &ere'ral is&he"ia+ PAST HISTORY Us(al &hildhood diseases+ No )$ow$ aller%ies+ The #a ie$ has a lo$% his ory o! ar hri is a$d she was hos#i ali.ed 1/ years a%o 'e&a(se o! ar hri is+ No "a0or o#era io$s a$d $o serio(s ill$esses i$ he #as his ory+ FAMILY HISTORY1 U$&o$ ri'( ory+ PHYSI2AL E3AMINATION GENERAL1 Physi&al e-a"i$a io$ re,eals a well-de,elo#ed* well-$o(rished* sli%h ly o'ese whi e !e"ale #a ie$ i$ a&( e dis ress+ 4ys#$ei&* '( $o &ya$o i&* ,ery wea)* disorie$ ed+ 5ITAL SIGNS1 O$ ad"issio$* her 'lood #ress(re is $or"al+ The #(lse was i$&reased o 167 'ea s #er "i$( e* re%(lar a$d she had a !as shallow res#ira io$ (# o 89+ HEENT1 EYES1 P(#ils are e:(al* rea& i$% o li%h a$d a&&o""oda io$+ 2o$0($& i,ae are #ale+ EAR* NOSE* THROAT1 Esse$ ially ($re"ar)a'le+ NE2;1 Thyroid* $or"al i$ si.e+ No &er,i&al ly"#hade$o#a hy+ No ,e$o(s dis e$ io$+ The $e&) is s(##le+ 2HEST1 The &hes is sy""e ri&al+ The 'reas s are $or"al !or her a%e wi h $o #al#a'le "asses+ LUNGS1 The l($%s are &o$%es ed 'ila erally wi h 'ro$&hial &o$%es io$ o$ 'o h #(l"o$ary !ields+ There is $o whee.i$% a$d here is $o da"#$ess o$ #er&(ssio$+ HEART1 There is a si$(s a&hy&ardia+ There is $o "(r"(r a$d here is $o &ardia& hy#er ro#hy+ A<4OMEN1 The a'do"e$ is so! + There is so"e e$der$ess o$ he e#i%as ri& re%io$ o$ #ress(re+ The li,er is #al#a'le 0(s 'elow he ri%h &os al "ar%i$+ The s#lee$ is $o #al#a'le+ <owel so($ds are #rese$ + There are a'$or"al "asses #al#a'le i$ a'do"e$+ No s(r%i&al s&ars a$d $o her$ia+ RE2TAL AN4 PEL5I2 E3AMINATION1 4e!erred+ E3TREMITIES1 There is $o #i i$% ede"a a$d ,ari&osi ies+ There are so"e ar hri i& &ha$%es i$ all e- re"i ies a$d he s#i$e+ 4IAGNOSES1 Possi'le #$e("o$ia* &ere'ral is&he"ia* a$d a$e"ia+